Flu Shot

SECTION A

 /  /
 Male  Female
Flu Shot Flu Nasal Spray (live) ages 2 to 49 only Pneumonia Other

SECTION B

The following questions will help us determine your eligibility to be vaccinated today. For All Vaccines: Please answer questions 1- 9.
For Live Vaccines (e.g. Live Attenuated Influenza Nasal Spray or Zostavax): Please answer questions 1 - 17
YES NO DON'T KNOW
All Vaccines
1. Which vaccines are you requesting to have administered today?
Please list all requested vaccines:
2. Do you feel sick today?
3. Do you have allergies to medications, food or any vaccine? (Examples: Eggs, Bovine Protein, Gelatin, Gentamicin, Polymyxin, Neomycin, Phenol or Thimerosal)
If yes, please list the allergies:
4. Have you received any vaccinations in the past 4 weeks?
If yes, please list the immunization:
5. Have you ever had a serious reaction to an influenza vaccine or any other vaccine in the past?
6. Have you ever had a seizure disorder for which you are on seizure medication(s), a brain disorder, Guillain-Barre Syndrome (a condition that causes paralysis) or other nervous system problem?
7. Are you 65 years of age or older OR do you smoke OR have a chronic condition (such as asthma or diabetes)?
8. If you answered YES to question #7 , have you ever had a pneumococcal, or “Pneumonia,” vaccination?
9. For women: Are you pregnant or considering becoming pregnant in the next month?
Live Vaccines
10. Do you have cancer, leukemia, lymphoma, HIV/AIDS or any other immune system disorder or are in contact with anyone who has a severely weakened immune system?
11. Are you currently on home infusions, weekly injections and/or taking medications such as Remicade®, Enbrel®, Humira®, Kineret®? Please refer to your health care provider if unsure about medication history.
12. Do you take cortisone, prednisone, other steroids, anticancer drugs or have had radiation treatments?
13. Have you received a transfusion of blood or blood products, or been given a medicine called immune (gamma) globulin in the past year?
14. Are you receiving aspirin therapy or aspirin-containing therapy? (18 years of age and younger only)
15. Do you have a long-term health problem with heart disease, lung disease, asthma, kidney disease, metabolic disease (e.g. diabetes), anemia or other blood disorder?
16. If the patient receiving vaccine is under 5 years old, does he/she have a history of asthma or wheezing?
17. Does the patient have a nasal condition serious enough to make breathing difficult, such as a very stuffy nose? (for FluMist® only)
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